One problem encountered by both physicians and patients in the managed care system is the delays it causes. Studies reveal that in many cases, managed care organizations delay responses to requests for medical services for more than two or three days. Physicians feel it is non-physicians managing the system who have no medical training that causes the delay. Patients feel that the system is designed to deny rather than improve services. Despite the reasons, studies reveal that the delays are too often dangerous for the patient.
In this regard, the managed care system often requires service providers to seek authorization before providing certain services for a customer. In some cases, such authorization is improperly denied, to the detriment of the customer's welfare. The denial may arise because individuals who decided to deny the authorization were not sufficiently knowledgeable and/or because the individuals did not have the proper and/or necessary information at their disposal at the time of the decision. Although historically, management of medical care and delivery of services were in the hands of physicians, more recently, the management of medical care has been relegated to persons who are not physicians. This change is mainly due to an attempt to control the increasingly excessive costs associated with those medical services.
As one example, in an industry such as the health-care industry, certain services may be denied to a patient because decision-makers do not have at their disposal information that would support a decision to grant the services. For example, medical providers may use diagnostic codes to identify certain medical conditions. Based on an erroneous diagnostic code entered by a provider, an administrator may improperly deny a patient a certain service, e.g., a magnetic resonance imaging (MRI) of the shoulder. Although a review of the patient's medical history (e.g., medical chart) would have revealed instances of arthritis which would have made an MRI appropriate, an erroneously entered diagnostic code for an instance of trauma instead of arthritis results in the denial of the MRI. As such, medical personnel attending to the patient cannot perform the MRI, which should have been performed to treat the patient's arthritis.
As another example, reimbursement for services already provided is not approved because authorization for the services was not previously granted. For example, a coma victim may be refused reimbursement for costs associated with traveling to the hospital via ambulance because authorization for this service was not granted before the service was provided.
Studies also reveal that the nurses and managed care personnel often make decisions with insufficient information, and achieve results contrary to the best interests of the patient.
Another problem with current managed care systems is the high costs associated with such systems. The average cost to insurance companies for delivery of managed care plans ranges between $50 and $150. The reason for the increased cost is because the nursing staff, who is required to make the decisions, may take from a few hours to a few days, in making such decisions.
Prior art systems and methods exist for allowing a claims processing person to detect fraudulent medical claims that are submitted for reimbursement or payment. Although such prior art systems analyze the submitted service codes during claims processing, such analysis is for ensuring that the payment for the medical services that were already provided is appropriate. The analysis is not for improving the medical services that are provided to patients, nor to allow those medical services to be provided more efficiently.
In fact, because the submitting of the claim generally means that the service has already been performed, even if a prior art system were to substitute a procedure code that is listed in a medical claim for payment with another more appropriate code, the medical provider would not be able to change the actual procedure that would already have been performed. This may be a detriment to not only a patient that could have received a more appropriate service, but also to the rendering medical provider who is only able to get reimbursed for the procedure that should have been provided, but not the service that was actually provided.
As such, there is a need for a computerized medical care system for providing service providers and service personnel with information that is useful in providing an improved and more efficient level of service to the customers that they serve.